Powerpoint presentation

Unsafe Use of Intravenous Haloperidol Pervasive in Hospitalized Elderly
University of Colorado Hospital and University of Colorado Denver at Anschutz Medical Campus, Aurora, Colorado
BackgroundLimitations
Delirium is present in 11-24% of elderly patients on hospital
556 patients received IV haloperidol during the study period.
admission while another 6-56% will develop it during their
Median size of the first dose of haloperidol given is 2 mg (range
Only the first haloperidol doses were recorded so events
associated with prolonged or cumulative doses of haloperidol
Off-label intravenous (IV) administration of haloperidol is often
20% received ≥ 5 mg of haloperidol for their first dose.
may be missed which may underestimate unsafe use.
used due to its rapid onset and ease of administration.4
80% had an ECG within 7 days of their first dose. (Measure 1)
We did not account for transient factors (i.e. electrolyte
Numerous case reports of QT prolongation, Torsades de Pointes
16% received IV haloperidol despite having a baseline QTc ≥ 500
disturbances) that may have affected QTc.
(TdP), and sudden death is associated with IV haloperidol.
In 2007, FDA issued a black box warning for IV haloperidol due
Only 21% of patients with a baseline QTc ≥ 450 ms had a repeat
the risk of adverse outcomes from QT prolongation.5
ECG measured within 24 hrs after the first dose. (Measure 3)
ConclusionTable 1: Characteristics of Study Population
Off-label IV haloperidol use is common among hospitalized
58% of patients in this analysis did not receive care concordant
To determine whether hospitalized elderly patients who are
prescribed IV haloperidol receive expert recommendation-concordant
More than 1 in 10 elderly patients received IV haloperidol despite
care to minimize adverse events related to QT prolongation.
a QTc ≥ 500 ms even after the FDA black box warning was
An adverse outcome in a patient receiving IV haloperidol with
known prolonged QTc may have significant medico legal
Retrospective study of patients ≥ 65 years who received ≥ 1 dose
Interventions to improve physician prescribing and assure proper
of IV haloperidol at the University of Colorado Hospital (UCH)
monitoring for this medication should be implemented.
Concomittant QT Prolonging Drugs - no. (%)
Patient demographics, co-morbid conditions, and QTc from
References
electrocardiogram (ECG) were collected from electronic medical
Inouye SK. Delirium in older persons. NEJM 2006; 354(11):1156-65.
Date of first dose of haloperidol administered, amount given, and
Saxena S, Lawley D. Delirium in the elderly: a clinical review. Postgrad Med
concomitant QT prolonging drugs were obtained from electronic
Expert Recommendation Non-Adherence
Fong TG, Tulebae SR, Inouye SK. Delirium in elderly adults: diagnosis,
prevention, and treatment. Nat Rev Neurol 2009;5:210-20.
Adherence to expert recommendations defined as meeting the
Haloperidol Injection USP (for immediate release) Package Insert. Bedford,
Information for Healthcare Professionals: Haloperidol. Available at:
ECG performed within 7 days before administration of
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPat
ientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm0852
IV haloperidol administration avoided if QTc ≥ 500 ms
Crouch MA, Limon L, Cassano AT. Clinical relevance and management of
ECG performed to reevaluate QTc within 24 hours after
drug-related QT interval prolongation. Pharmacotherapy 2003;23(7):881-908.
first dose of haloperidol if prior QTc ≥ 450 ms
Li EC, Esterly JS, Pohl S, et al. Drug-induced QT-interval prolongation:
considerations for the clinicians. Pharmacotherapy 2010;30(7):684-701.
Measures

Report for Brighton and Hove Health and Wellbeing Board (HWBB) and Clinical Commissioning Group (CCG) 9.8.13 By John Kapp, 22, Saxon Rd Hove BN3 4LE, 01273 417997, johnkapp@btinternet.com CURING THE NHS AND DEPRESSED PATIENTS BY MASS-COMMISSIONING THE MINDFULNESS COURSE The crisis in the NHS is caused by the following factors, which can be solved locally by councillors initiating culture change

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